ESCRS Today - 17 September 2022

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ESCRS Today is a daily newspaper packed with highlights of the day’s main events and industry symposia.

Welcome to the 40th ESCRS congress in Milano!


want to extend a very warm welcome to everyone attending this year’s ESCRS Congress. We are thrilled to be back to full size in one of the largest convention centres in Europe, with 65 meeting rooms and 50,000 square metres of exhibition space. We got off to a great start on Friday with our new iNovation symposium. This new ESCRS interactive event brought together clinical and business experts from across Europe and other parts of the world. Sessions focused on the most urgent clinical needs and barriers to success in anterior segment care—and how the latest technology innovations may address the clinical needs within the next few years. Also on Friday, delegates were able to attend our specialty day events in paediatrics, cornea, and glaucoma. And we are just getting started. We have come a long way since our annual Congress in Amsterdam last year. There, we were happy to meet in person again but still couldn’t help but be preoccupied with the COVID pandemic. This year, thankfully, wide-scale vaccination and

improved treatment mean we can meet with fewer restrictions. Other global events remind us of the role we can play as ophthalmologists on the world stage. The ESCRS responded very quickly to the Russian invasion of Ukraine. Our ongoing





CHAIRMAN: Gok Ratnarajan

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16:00 - 17:00



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efforts, working with industry, have already provided more than one million euros in support to our Ukrainian ophthalmological colleagues in logistics and medical supplies. We also received strong support from sister societies throughout the world. All Ukrainian doctors have been offered free registration to the Congress. We expect around 300 doctors will attend. We’ll be giving out 23 observerships and some 7 travel grants. We are also highlighting the crisis in Ukraine in several special sessions. No issue has broader global ramifications for all of us than climate change. You will notice signs of our enhanced commitment to making ophthalmology more sustainable

This year’s programme is the largest we have ever assembled. throughout the conference—recycling, reusable water bottles, messenger bikes, and healthy snack options everywhere. Sustainability will also be a hot topic at sessions throughout the meeting as we explore ways to reduce operating room waste and optimise our resources. Our vision is at the ESCRS in Vienna in 2023, we will have a Congress with zero waste to landfills zero net carbon emissions, and we will be a role model for social responsibility. This year’s programme is the largest we have ever assembled. You will see the old favourites like the Main Symposia, Clinical Research Symposia, the JCRS Symposium, the Video Symposium on Challenging Cases, clinical courses, free papers, and posters. We increased the number of wetlabs to more than 100 to compensate for the last year, when no wetlabs were possible. We have new offerings, including a fully revamped Practice Management and Development Programme. You can also learn about our new ESCRS IOL calculator, which will go online in Milan. We realise it would be impossible to see everything during the meeting, so we want to remind you that many sessions are streamed and can be watched later. Our exhibit hall is also back to full size with more than 200 booths. There will be 25 industry-sponsored satellite symposia, providing updates on every aspect of ophthalmic surgery. Make sure to grab a copy of our daily newspaper to keep up with the latest happening at the conference. I hope you will also be able to find the time to enjoy all that Milan has to offer—food, fashion, culture, and nightlife.


All photography by Andrea Adami





Education, Technology Drive Presbyopia-Correcting IOL Acceptance Currently, 55% of ESCRS members surveyed either don’t implant presbyopia-correcting intraocular lenses (PCIOLs) or implant them in fewer than 5% of eligible patients. But twothirds see their usage increasing in the next year. Educating patients, surgeons, and staff about PCIOL options as well as improvements in lens, diagnostic, and lens power calculation technology are driving the advance, surgeons and industry representatives said at the inaugural ESCRS iNovation program Friday. “If you look in the literature, there are about 1.5 billion people with presbyopia, so there is a huge need,” said Thomas Kohnen MD, PhD of Germany, who moderated a session on managing presbyopia from early stage to cataracts. Current choices of PCIOLs range from monofocal+ lenses to extended depth of focus lenses to multifocal lenses, each of which offer different advantages and trade-offs. Raj Rajpal of Johnson + Johnson Vision noted that PCIOL sales have grown to 11% of IOL sales in the European market, compared with about 8% globally. He gave three reasons for the growth. First is growing patient awareness, often driven by word of mouth among a population that may not be active social media users. “Patients are coming in and asking about [PCIOLs],” he said. Second, surgeons are getting better at all aspects of implanting PCIOLs, including educating patients on the visual trade-offs involved and evaluating post-surgery visual needs. Surgeons are also getting better at managing complications and becoming more confident in making lens power calculations. Younger surgeons also may be more likely to be aware of the range of PCIOL options because they were exposed to them in training, Rajpal said.

Third, the technology has advanced, reducing issues such as night vision problems, Rajpal added. Even so, after cost, night vision issues remain the number-two issue preventing greater uptake, according to latest ESCRS survey.


Gerd U Auffarth MD of Germany believes cost is the major obstacle to greater PCIOL uptake. For a surgeon with a successful monofocal practice, spending more time counselling, evaluating and following up on patients for premium lenses makes no economic sense, especially if their health system does not pay more or allow patient billing. “If they need to work 30% more but they don’t get more money for it, they decide to stick with [monofocals].” However, the advent of monofocal+ technology may help bring some of these doctors onboard as they begin to see the patient benefits. Only one-third of patients are educated or well educated on refractive options at their initial consult, and just over half of surgeons are confident in their ability to educate them on the financial costs. Still, 73% are confident in their ability to educate patients on the trade-offs of PCIOLs, the ESCRS survey found. Arthur Cummings MD emphasised not only the need to educate patients, but also doctors and staff. If you don’t do refractive lenses, refer to someone who does. If you do, make sure every person in the practice knows about the options, and talks positively to patients about them. User groups are a good place to learn about the finer points of everything from talking to patients to predicting IOL power, Dr Cummings said. “If we have education of the patients and education of the doctors, we will see a huge increase.”


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Annual ESCRS Clinical Trends Survey Underway The eighth annual ESCRS Clinical Trends Survey (at right) launched during the ESCRS iNovation Symposium on Friday. This survey builds upon the success of prior surveys, which have included more than 10,000 participants to date. The survey asks ESCRS delegates key questions on current issues they regularly face in their practice. The goal is to obtain opinions from a significant percentage of delegates and for ESCRS leadership to review the results. Building on last year’s survey, the 2022 survey adds questions in evolving clinical and technology areas such as uveitis and myopia management. Data from prior surveys helped develop content for many of the symposia at this year’s ESCRS Clinical Forum IME programmes. Information from the 2022 survey will be used to continue to drive these efforts and discover new areas of education. The 2022 ESCRS Clinical Trends Survey includes a wide range of contemporary topics, including presbyopia correction, astigmatism management, ocular surface disease, cataract extraction, glaucoma, and corneal refractive.

The survey can be completed in person at the ESCRS Congress in Milan at the Survey Lounge located in Hall 4 on September 16th – 18th. Seating and free refreshments will be provided to survey takers. If you are not able to complete this survey during the Congress in Milan, we encourage you to take this 15-minute survey by going to Please complete the survey as soon as possible, as the closing date will be Saturday, October 15th, 2022. By completing the survey—and filling in your email address— respondents will be entered into a raffle to win a free delegate registration for the ESCRS 2023 Congress in Vienna. Additionally, every participant will receive an emailed summary of the data shortly after it’s compiled. Finally, and most importantly, by completing the survey, you will be providing important data to help drive future education programming. If desired, respondents can choose to remain anonymous and still complete the survey, providing ESCRS with important feedback.

th oo t b a it Vis /B78 022 6 B8 RS 2 C ES

EYESI SURGICAL Cataract surgery virtual reality (VR) training experience

ESCRS delegates are invited to attend a ‘Cataract surgery This 20-minute training experience will allow trainees to virtual reality (VR) training experience’, and witness some of see the surgical field in stereo and high-resolution, while the exciting features of the Eyesi Surgical Simulator, first-hand. operating with life-like surgical instruments. Places are limited, visit to secure your place, or visit booth B86/B78 to check availability.


Complete This Survey and Have a Chance to Win the Daily Raffle for a Free ESCRS 2023 Annual Congress Registration Winners will be announced at the Survey Lounge Area, Hall 4 at 15:15 on Friday 16 September, 16:15 on Saturday 17 and Sunday 18 September Doctors Have Several Options to Complete Survey


Take the survey at the Survey Lounge Area, Hall 4, while resting your feet and enjoying a FREE refreshment.

The Clinical Trends Survey evaluates clinical opinions and practice patterns of ESCRS doctors.


On your device: ESCRS doctors go to:

Your confidential responses, through this 15-minute survey, will be reviewed by the ESCRS leadership and drive future education programs.


Scan the QR code to be directed to the survey website.


In 15 minutes, you can make a difference! Complete this 15 minute survey, giving us your perspectives on the key issues facing ophthalmology today...

WIN A FREE 2023 Annual Congress Delegates Registration For admission on Friday, Saturday and Sunday...

By completing this survey, we will... Enter you in a daily raffle to WIN A FREE 2023 ANNUAL CONGRESS DELEGATE REGISTRATION.



Email you the preliminary report before it is published and publicly available.

ESCRS Leadership will use your confidential feedback in future publications, educational symposia & to determine education needs.

Good Luck!




Weighing options in cataract and corneal endothelial disease Several viable options exist for the surgical treatment of patients with concomitant cataract and corneal endothelial disease, but there is no “one size fits all” approach that consistently delivers optimal outcomes for these complex cases, according to Björn Bachmann MD, FEBO. Speaking at the Cornea Day session on cataract surgery in the patient with ocular comorbidity, Dr Bachmann noted the increasing demand in recent years for so-called triple Descemet membrane endothelial keratoplasty (DMEK) surgery, which combines cataract surgery, IOL implantation, and DMEK in one procedure. “There is a significant and growing population of patients with cataract and corneal endothelial diseases, and we need to have a strategy to be able to deal with them in the future,” he said. Dr Bachmann said that the key question is whether combined (triple-DMEK) or sequential cataract surgery and endothelial keratoplasty is the best approach for these patients. “All surgical approaches have their advantages and disadvantages,” he said. “The advantages of triple-DMEK are that phacoemulsification and lens implantation do not affect the graft, while the downside is inaccurate IOL calculation and variable pupil size during DMEK with this approach.” There are two options for sequential surgery, said Dr Bachmann: cataract surgery and then DMEK surgery, or DMEK surgery followed by cataract surgery. “The advantage of the first approach is that DMEK may be avoided if the patient is satisfied and comfortable after cataract

surgery alone,” he said. “The disadvantage is the possibility of further endothelial decompensation and corneal opacification while waiting for DMEK. And there is also the risk of a hyperopic shift if the patient does proceed to have DMEK surgery.” If the surgeries are inversed and DMEK is performed first, the main advantage is improved predictability of IOL calculation, while the downside is that the cataract surgery will decrease the endothelial cell density of the DMEK graft, said Dr Bachmann. Based on the available evidence and his own clinical experience, Dr Bachmann said that triple-DMEK is a viable option in patients with pronounced corneal oedema and cataract with significantly reduced visual acuity.

There is a significant and growing population of patients with cataract and corneal endothelial diseases, and we need to have a strategy to be able to deal with them in the future.

“These patients will benefit in quality-of-life gain through rapid success with combined surgery, although it is important to take into account the presumed postoperative posterior to anterior corneal curvature radii ratio to ensure optimal outcomes in these cases,” he said. Patients with mild corneal oedema and mild cataract might be bothered by postoperative refractive error, he said. “Consider DMEK first in extremely demanding patients and again take into the account the true posterior to anterior corneal curvature radii ratio for the IOL calculation,” he said. For patients without corneal oedema and with cataract, Dr Bachmann advised cataract surgery first to see whether the problem has been sufficiently resolved and transplant surgery might be avoided.

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Approaching glaucoma patient care with a holistic view In caring for patients with glaucoma, ophthalmologists need to ask about systemic medical conditions and medications because certain findings in these histories have effects on IOP and glaucoma risk, said Gerhard Garhöfer, MD, at the ESCRS Glaucoma Day. “It makes sense to look at our patients as a whole. We should not only concentrate on the eye,” said Dr Garhöfer, Medical University of Vienna, Austria. Learning about a patient’s blood pressure (BP) and existing treatment for systemic hypertension is important, especially

glaucoma. However, ocular perfusion pressure cannot be directly measured, and the take-home message for clinicians on this topic is to be aware that patients with a very high IOP and a low BP are at considerably increased risk for glaucoma. For patients who are being treated for systemic hypertension, ophthalmologists should ascertain use of a beta-blocker. “Be aware that patients receiving systemic treatment with a beta-blocker have an average 1.0 to 1.5 mmHg reduction in IOP,” Dr Garhöfer said. “Topical beta-blocker therapy for glaucoma may be less effective in patients on a systemic beta blocker, and taking oral and topical beta blockers together is associated with an increased risk for adverse effects.” Ophthalmologists should also be aware that patients who are being treated aggressively for their systemic hypertension with the goal of managing cardiovascular risk may suffer from nocturnal dips in BP that have been shown to increase risk of glaucoma progression. Dr Garhöfer suggested obtaining 24-hour BP measurements in these individuals. Regarding other systemic diseases, he noted that a variety of inflammatory and autoimmune systemic conditions can also involve ocular structures and lead to increased IOP. The list includes sarcoidosis, Bechet’s disease, HLAB27-related uveitis, juvenile idiopathic arthritis-associated uveitis, and Vogt-Koyanagi-Harada syndrome. Considering that glaucoma prevalence increases with age, clinicians should recognise there is also an age-related increase in systemic medication use and that certain medications increase IOP. “Two-thirds of adults aged 48 to 64 years, and 90% of people aged 65 years and older, take five or more medications,” Dr Garhöfer said. “Do not only ask patients what diseases they have, but also what medications they are taking.” Corticosteroids, which are commonly used, represent the classic culprit, and this class of medications can lead to increased IOP regardless of the route of administration. Moreover, 30% of patients using corticosteroids experience an increase in IOP, and approximately 5% of individuals are “high responders,” meaning their IOP will increase significantly.

Be aware that patients receiving systemic treatment with a beta-blocker have an average 1.0 to 1.5 mmHg reduction in IOP. considering that almost one-third of the world’s adult population suffers from systemic hypertension. “I am pretty sure that all of you have received questions from patients asking whether their systemic hypertension influences their glaucoma,” Dr Garhöfer noted. The answer is somewhat complicated, he said. Although the available data show a statistical association between increased BP and increased IOP, the association is very weak from a clinical point of view. An effect of low systemic BP on glaucoma risk has also generated interest, considering evidence pertaining to relationships between systemic BP and ocular perfusion pressure and between ocular perfusion pressure and

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AI on the horizon for glaucoma patient care Artificial intelligence (AI) in glaucoma has great potential and will become important for patient care in the future, but it is still not ready for clinical application, said Marta Pazos, MD, at the ESCRS Glaucoma Day. “AI is no longer a futuristic thing. It is already here, and there are many publications demonstrating its use for glaucoma detection and management,” Dr Pazos said. “But the 5th edition of the European Glaucoma Society guidelines states that we should not base our clinical decisions on AI only. That is because there are several challenges that need to be solved.” The opportunities that AI can bring to glaucoma include automating glaucoma detection, aiding with clinical decisions, and predictive analysis (personalised medicine). Automated glaucoma detection has applicability for virtual clinics that can reach underserved areas, provide telehealth visits, and be used in primary care to improve patient triaging. For decision support, AI will be used by clinicians in their electronic health systems, where it can flag areas to look at more carefully or raise alerts that a patient may be showing signs of progression. Predictive analytics takes advantage of the huge amounts of available data to guide more precise management and treatment for patients, Dr Pazos said. “We are moving more from evidence-based medicine to precision medicine to personalised medicine, where we will base our treatment and management decisions on real-world data, not on artificial data that come from clinical trials, which have strict inclusion criteria and that lead to a one-size fits all approach,” she said. “Using AI tools will help us to give a more individualised approach. The predictive analytics branch will help with risk assessment and profiling, so you will know what test to do for which patient and at what frequency.”

AI is no longer a futuristic thing. It is already here, and there are many publications demonstrating its use for glaucoma detection and management.


Data sources for AI in glaucoma are numerous and include retinal photographs, visual fields, OCT and OCT angiography, electronic health records, genomics, and public data sets. “And we know that when you use a multimodal approach, your results are much better,” said Dr Pazos. AI research in glaucoma has expanded in recent years and has demonstrated performance for disease detection and predicting progression. The barriers to its implementation, however, are that AI algorithms are often built and validated in a small number of centres with very specific instruments. Therefore, the algorithms may not be representative. In addition, the available data are heterogeneous, there is a lack of structured databases, and there is huge diversity across European healthcare systems. The main barrier, however, is a problem of trust. “There are potential risk and ethical and legal implications, and many stakeholders perceive AI algorithms as opaque and difficult to understand,” said Dr Pazos. Attention to data quality, data ownership, and generalisability can improve AI trustworthiness, she stressed.


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Welcome Ukrainian Ophthalmologists! The ESCRS wants to extend a special welcome to our Ukrainian colleagues. All Ukrainian doctors have been offered free registration to the Congress, with some 300 doctors expected to attend. The ESCRS responded very quickly to the Russian invasion of Ukraine in February of this year. Our ongoing efforts, working with colleagues in other ophthalmology organisations and industry, have already provided more than one million euros in support to our Ukrainian ophthalmological colleagues in logistics and medical supplies. “From the first day of the beginning of the War against Ukrainian people, principals of democracy and humanism, we, Ukrainian ophthalmic surgeons, felt your support. Every day you ask me about the situation in my country, and every day you propose possible help. We feel it, and we are very appreciative.My country, our citizens, and our

army show unbelievable examples of heroism. We are the first barrier on the way in Europe of Russian Federation dictation, military aggression, and inhuman suffering. And we believe that truth will win,” said Volodymyr Melnyk MD, Head of the Society of Ukrainian Ophthalmic Surgeons in a letter to all ESCRS members. The ESCRS has also arranged to provide observerships and some travel grants for Ukrainian colleagues. The travel grants are primarily for older surgeons who have suffered particular losses or been under particular pressure. The observerships— selected by an ESCRS panel—will be for trainees. So far, observerships have been established in Auckland, New Zealand and in Utah, United States. These are funded in part from ESCRS reserves and in part from the funds generously donated by other organisations, especially sister societies and individuals.

HOW TO HELP • ESCRS has established a fund to accept financial donations that will be directed exclusively to support ophthalmology-related relief efforts arising from the conflict in Ukraine. We can accept donations to the fund from ESCRS members, industry partners, and fellow societies. • We can accept these donations through bank transfer. If you are an ESCRS member and wish to contribute, please simply log in to using your membership details to access information on how to donate, which is a straightforward process. • For industry partners or fellow societies, please email escrs@ for information on how to make your donation.


Here at the Milan Congress, there will be a War Trauma symposium in which, not least, there will be some interesting case studies presented by Ukrainian surgeons—whose experience dates back to 2014 when the first invasion of Donbas took place. Orbis is hosting a symposium, “Innovative Ophthalmology in Conflict Zones,” in which Ukraine will also figure. “I would again like to thank our industry partners, sister societies, and members for supporting us in our efforts to assist colleagues in Ukraine. I think we have made a significant and targeted difference in many trauma centres across Ukraine, and I know it has been greatly appreciated. Your help in sustaining this support into 2023 will be invaluable,” said Oliver Findl MD, President of the ESCRS.

oth t bo at i s i V 8 /B7 B86 S 2022 R ESC

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Swept-source OCT for cataract & refractive surgery

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The Symposium will take place at 9:30AM on Sunday 18th September 2022 in Space 4 Session Room, MiCo Milano Convention Centre.

Places are limited, delegates are encouraged to arrive at the Space 4 Session Room between 9:00AM-9:15AM.





coming to grips with ocular surface disease in cataract patients Ocular surface disease (OSD) is a major cause of suboptimal cataract surgery outcomes, but having a clear strategy and ensuring careful preoperative screening to detect potential issues can help to avoid many of the pitfalls associated with OSD in cataract patients, according to a presentation at yesterday’s Cornea Day session. Allan R. Slomovic MD, professor of ophthalmology at the University of Toronto, Canada, focused his presentation on three principal ocular surface problems: pterygium, epithelial basement membrane dystrophy (EBMD), and dry eye disease (DED).

If you tell the patient about their ocular surface disease before the surgery, they own it. To effectively deal with a patient who presents with both pterygium and cataract, it is critical to understand the effects that the pterygium has on corneal topography. “It causes flattening of the cornea in the area of the pterygium, results in irregular with-the-rule astigmatism and an increase in higher order aberrations,” he said. Dr Slomovic advised first removing the pterygium with a conjunctival autograft, then waiting six to eight weeks to obtain stable keratometry and topography. Once this has been achieved, the surgeon can proceed with biometry and phacoemulsification to remove the cataract. Anterior basement membrane dystrophy is the most common corneal dystrophy and is especially significant if the changes are manifested in the visual axis, explained Dr Slomovic. He presented the case of a 75-year-old male with declining visual acuity who was referred for consideration of cataract surgery. The patient had two central Salzmaan nodules and irregular astigmatism. Six weeks

after superficial keratectomy to remove the nodules, the bestcorrected visual acuity recovered to 20/25 and cataract surgery was avoided. For cases of DED, Dr Slomovic emphasized the importance of addressing the problem preoperatively. “DED can cause corneal staining and abnormalities in keratometry, topography and biometry,” he said. “Dry eye treatment leads to changes in IOL power calculations and postoperative refractive outcomes. Therefore, assessing and treating patients for dry eyes prior to cataract surgery is important in maximizing refractive outcomes.” The role of the ophthalmologist is to optimize the ocular surface prior to and after surgery and to set realistic expectations by explaining to the patient that they have two separate conditions that need to be treated, he said. “If you tell the patient about their ocular surface disease before the surgery, they own it,” he said. “However, if they only become aware of it after the cataract surgery, they will presume that the surgeon caused the problem.” Particular vigilance is needed in the use of non-steroidal anti-inflammatory drugs (NSAIDS) in the presence of DED, as it can lead to corneal melts and perforation, warned Dr Slomovic. “We now have seven studies in the scientific literature reporting the association of NSAIDS and corneal melts in the setting of cataract surgery,” he said.


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ESCRS looks to the future­—Starting with sustainability now Starting on Friday during the iNovation Symposium, then the opening ceremony on Saturday, and through to Tuesday, sustainability is a thread woven through the fabric of this year’s Congress. Indeed, the ESCRS worked for many months to organise a net zero waste and emissions Congress. The ESCRS is committed to calculating, reducing, and offsetting the event’s carbon emissions. It began at the online registration, where members could choose a Gold Standard-certified, carbon-offsetting option. Members also have the opportunity to take the ESCRS Zero Emission Sustainability Pledge to help carry the message home after the meeting. As you enter the registration area at MiCo, you will see a sustainability wall installation. There will be sessions throughout the conference looking at improving sustainability in all areas of ophthalmology, from manufacturing to the operating room. Panellists will discuss potential ways to eliminate waste, emissions, and pollution, including recycling materials and products and switching to more sustainable materials. You can keep track of these sessions by checking the sustainability track on your online programme. ESCRS members as well as exhibitors are asked to take

steps to reduce our communal carbon footprint. This starts with traveling more sustainably to and from the meeting by taking a train instead of a plane when possible. Next would be to choose a hotel with a Green Globes sustainability rating. During the conference, members can take advantage

Some of the goals of the ESCRS sustainability initiatives are: • • • • • •

Eliminate waste, emissions, and pollution Recycle materials and products Switch to more sustainable materials Regenerate natural systems (people and planet) Design for inclusiveness and diversity Use our sustainability efforts to improve participants’ event experience

of healthier and climate-friendlier food and drink options. Conference planners worked to eliminate single-use plastic water bottles in favour of water stations and bespoke reusable bottles. The Congress has also implemented an advanced recycling system. To make a sustainable congress requires commitment and collective action from participants, exhibitors, sponsors, organisers, and suppliers. Our approach is to engage, inspire, and catalyse collective action to make a zero-impact event. Thank you for helping us to reach these goals. Practicing sustainability is a learning experience for all of us. A sustainability report identifying effective strategies, best practices, and lessons from Milan will be produced after the Congress and applied to planning next year’s Congress in Vienna and other future ESCRS events—with the goal of creating net zero carbon emission events.




What are your patients thinking? Ask them! BY CLARE QUIGLEY MD The Practice Management and Development Course returns to the ESCRS Congress in Milan for the first time since 2019. Shareef Mahdavi will be delivering the masterclass in practice management: “Beyond Bedside Manner—How Ophthalmologists Can Optimise the Patient Experience”. In this workshop, Mr Mahdavi and a panel including Paul Rosen, Amanda Carones, Sheraz Daya, and Arthur Cummings (among others) will explore what matters to patients in their eyecare experience, highlighting ophthalmologists’ blind spots and revealing how to do better. The content derives from Beyond Bedside Manner, Mahdavi’s book on enhancing the patient experience. EuroTimes reporter Clare Quigley MD talked with Mr Mahdavi about the upcoming course. What are you going to cover in the masterclass? Shareef Mahdavi: I will uncover the toolkit an eye surgeon has to improve their practice. The takeaway at the end of the day: I hope people will come away with some actionable ideas they can bring back to their practice and start implementing straightaway. They will have a new appreciation for the patient experience in the overall picture. How can ophthalmologists assess patient experience in their own practice? They need to ask them. Broadly there are two ways: patient surveys and patient reviews. There are plenty of tools out there you can incorporate to help automate the process. Surveys should measure satisfaction, including a few key questions, such as measuring level of agreement with a phrase like: “I would willingly recommend ABC eyecare to my friends and family that need eyecare”. You want 100% of your patients to choose “strongly agree”. If 100% don’t strongly agree, you need to find out why that is and start asking more questions. Was it the scheduling, or how they were treated when they arrived? Or was it their interaction with the doctor? The biggest problem patients will complain about is waiting. Doctors should ask for patient reviews to start a feedback loop to initiate improvements to their service. We are going to cover the importance of this. How would you go about getting feedback? There are a couple of ways. Carrying out a survey can be very straightforward—you can simply email the patient and use a tool like SurveyMonkey. Alternatively, you can do something very basic, like emailing to ask them, “How did we do?” That can generate useful feedback. Reviews are different—they have

the added benefit of spreading the word about your practice. You can email the patient, a process that can be automated, and ask them to please write a review, and send links to a couple of review sites. There are rules around this, including that the patient should write the review at home, not from the clinic. The review sites want legitimate reviews. Then there are other more sophisticated ways of obtaining reviews, including by a third party, which can allow for a positive review to post to the practice website automatically, and if negative, instead get sent directly to the practice manager. Other industries have already developed tools that have been adapted for these healthcare reviews. Generalising, what areas should an ophthalmologist direct focus to see improvement in the patient experience? The greeting and the farewell. How do we greet people when they call on the telephone or when they arrive at the practice? That has nothing to do with the doctor’s skill and expertise. Doctors might say they don’t care if the patient has to wait an hour to see them. But another doctor will care, the patient cares, and so the patient will move to another provider. Patients’ brains do not shut down as consumers just because they are in a medical environment. Along with waiting times, the physical environment is important—patients are awake and aware of their surroundings, how clean and neat the reception is. If the chairs are uncomfortable, carpets stained, that does not inspire confidence. Thank you very much, Shareef—looking forward to the masterclass. For those interested in reading more, check out Beyond Bedside Manner, Shareef’s book of insights on improving patient experience, available on Amazon. The Practice Management Masterclass takes place on Sunday, 18 September from 09.00–17.00 in Room Brown 1. Practice Management workshops take place the following day from 08.30–18.00.

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WSPOS: Complex Cases in Paediatric Cataract Roberto Caputo MD, from Florence, Italy, discussed the complex problem of paediatric cataract in uveitis during the opening session of the World Society of Paediatric Ophthalmology and Strabismus. His approach to cataract in these cases is tailored to each patient. “I ask myself three questions,” Dr Caputo said. “First of all, who is the patient that I am going to treat? When can I do the surgery? And how can I do this surgery?” Dr Caputo highlighted that cataract in Juvenile Idiopathic Arthritis (JIA) is particularly challenging, with a high risk of complications. ”Can we really wait three months without relapses to do surgery?” he asked. The three month wait is a widespread approach to judging the safe time to wait until cataract surgery in a patient with uveitis, but Dr Caputo questioned whether this is always the best approach, especially in a child with a dense cataract. Marta Morales MD, Barcelona, Spain, discussed infant cataract surgery, including some important timing considerations. “It is not recommended to implant an IOL before seven months of age,” she said. “This is in particular

due to the risk of visual axis opacification and subsequent requirement for surgery.” “If we have a dense congenital cataract we should operate as soon as possible, but it is better not to operate before four weeks of age,” Dr Morales continued. “During this age, the anterior segment is still developing.” At this neonatal developmental stage, performing surgery can provoke glaucoma. Once timing is decided, choosing an appropriate intraocular lens implant is important, taking into account the growth of the eye. There are no paediatric IOL formulae. “The best formulae are SRKT or Holladay 1,” Dr Morales said. Erick Bothun MD, Rochester, Minnesota, went on to cover cataract surgery in toddlers. “There are challenges in paediatric cataract surgery across the board,” he said. “Most of the literature would suggest that older eyes do better.” The younger the patient, the greater the risk. “There is a higher rate of glaucoma, adverse events, complications.” “When is it safer to put IOLs in? After six months,” he said. Dr Bothun drew on data from the Toddler Aphakia and Pseudophakia Study (TAPS), drawing comparisons with the Infant Aphakia Treatment Study (IATS). “Largely, glaucoma risk drops off after six months of life.”

OPHTEC | Cataract Surgery

Hannah Scanga MD, genetic counsellor at UPMC Pittsburgh, US, talked about the genetics of paediatric cataract. “Your highest diagnostic rate will be found with bilateral cataracts,” Dr Scagna said. Determining a genetic cause starts with history and exam. “Also examine the parents,” she suggested. Important findings can help to narrow down investigation to a causal mutation—for example, findings in mothers who are carriers of Lowe syndrome, such as spokelike lens changes. “Genetic causes are being continued to be identified,” Dr Scanga said. “Customisation is helpful.” She suggested a multigene panel as an effective investigative tool. Göran Darius Hildebrand MD, Oxford, UK, reiterated that paediatric cataract surgery is a vital treatment and that problems arise in postponing surgery. “Delayed surgery leads to permanent brain damage in the form of amblyopia, strabismus and nystagmus.”

If we have a dense congenital cataract we should operate as soon as possible, but it is better not to operate before four weeks of age.

CTF/TCT optic designed to:  REDUCE GLARE & HALOS1

Dr Hildebrand was in agreement with Dr Morales that the best formulae available for use in children are SRKT and Holladay 1, as evidenced by a recent meta-analysis, Zhong et al, 2021. But even the best available formulae do not yield results that are comparable to the accuracy of biometry in adults. “The [rate of] absolute prediction error outside two dioptres reaches 50%.” This error rate is due to numerous factors specific to children, including technical issues obtaining biometry, and childhood emmetropisation. Dr Hildebrand went on to discuss different approaches to reduce visual axis opacification, highlighting the usefulness of the Bag-InThe-Lens (BIL), invented by Prof. Marie-José Tassignon. For surgeons without access to the BIL, optic capture of a sulcus IOL optic through the anterior and posterior capsule is a potential method to reduce risk of opacification of the visual axis.



1) Broader Toric meridian designed to be more tolerant of misalignment. White paper: Evaluation of a new toric IOL optic by means of intraoperative wavefront aberrometry (ORA system): the effect of IOL misalignment on cylinder reduction. By Erik L. Mertens, MD Medipolis Eye Center, Antwerp, Belgium 2) The misalignment tolerance and the use of segments instead of concentric rings reduces photic phenomena, helping patients to adapt more naturally to their new vision. 3) The central zone of 1.4 mm in diameter is larger than most available mIOLs and allows a wider tolerance so that the visual axis passes through the wider central segment avoiding visual disturbances. 4) In cases of tilt or misalignment, the patient can still benefit from good near and far vision, as the segmented zones allow a balanced far/near light distribution in a steady optical platform.



All photography by Andrea Adami



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Experience the latest evolution of the iStent® legacy of excellence in your practice. *Based on units sold. iStent inject® W IMPORTANT SAFETY INFORMATION INDICATION FOR USE: The iStent inject W, is intended to reduce intraocular pressure safely and effectively in patients diagnosed with primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma. The iStent inject W, can deliver two (2) stents on a single pass, through a single incision. The implant is designed to stent open a passage through the trabecular meshwork to allow for an increase in the facility of outflow and a subsequent reduction in intraocular pressure. The device is safe and effective when implanted in combination with cataract surgery in those subjects who require intraocular pressure reduction and/or would benefit from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and conventional glaucoma surgery. CONTRAINDICATIONS: The iStent inject W System is contraindicated under the following circumstances or conditions: • In eyes with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascular glaucoma, because the device would not be expected to work in such situations. • In patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS/PRECAUTIONS: • For prescription use only. • This device has not been studied in patients with uveitic glaucoma. • Do not use the device if the Tyvek® lid has been opened or the packaging appears damaged. In such cases, the sterility of the device may be compromised. • Due to the sharpness of certain injector components (i.e. the insertion sleeve and trocar), care should be exercised to grasp the injector body. Dispose of device in a sharps container. • iStent inject W is MR-Conditional; see MRI Information below. • Physician training is required prior to use of the iStent inject W System. • Do not re-use the stent(s) or injector, as this may result in infection and/or intraocular inflammation, as well as occurrence of potential postoperative adverse events as shown below under “Potential Complications.” • There are no known compatibility issues with the iStent inject W and other intraoperative devices. (e.g., viscoelastics) or glaucoma medications. • Unused product & packaging may be disposed of in accordance with facility procedures. Implanted medical devices and contaminated products must be disposed of as medical waste. • The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. If intraocular pressure is not adequately maintained after surgery, the surgeon should consider an appropriate treatment regimen to reduce intraocular pressure. • Patients should be informed that placement of the stents, without concomitant cataract surgery in phakic patients, can enhance the formation or progression of cataract. ADVERSE EVENTS: Please refer to Directions For Use for additional adverse event information. CAUTION: Please reference the Directions For Use labelling for a complete list of contraindications, warnings and adverse events. Glaukos®, iStent®, and iStent inject® W are registered trademarks of Glaukos Corporation. All rights reserved. ©2022 PM-EU-0187